Let's Talk About... Maternal Mortality - Abuse and Trauma During Labor

Let's review The Sexual Abuse to Maternal Mortality Pipeline as reported by The Institute for Gender and Culture at Black Women's Blueprint:

1. Sexual Abuse Occurs (trafficking, assault, rape)

2. Unaddressed Sexual Trauma and Neglect of Healing = higher possibility of re-traumatization

3. Weathering - lifelong chronic and cumulative exposure to social and economic stressors (racism, sexism, societal oppression) is toxic and associated with early onset of chronic illness such as heart disease

4. Avoidance/Delay of GYN, Maternal, and All Healthcare (teaching hospitals with many residents attending to one patient, institutions may be uninviting, not culturally affirming, fear or shame to be seen due to previous abuse)

5. Abuse in OBGYN and Prenatal Care (i.e. healthcare providers that are dismissive, minimizing of a patient's pain, we will get more into what this looks like below)

6. Trauma Symptoms Are Re-triggered or New Incidents of Abuse Occur (language and behavior of healthcare providers/others that triggers/re-traumatizes) 

7. OB Violence in Labor and Delivery (doctor burnout, compassion fatigue, use of force)

8. Maternal Mortality

When you walk into these healthcare institutions, you bring your trauma, and when this trauma is unresolved, it may manifest during labor.  Sexual trauma is more common than you would know, as many victims do not speak out due to stigma and fear.  For every woman who reports a rape, 15 do not.  There are 32k pregnancies from rape a year.  70% of women experience some form of sexual violence by their 18th birthday.  Sexual violence can produce over 150 medical consequences (STI's, Mental Health, PTSD, Pregnancy).

So now, you have an individual who has endured some kind of trauma, and in turn they develop a set of traumatic beliefs which more than likely include: 

1. 1. I am not safe
2. 2. People want to hurt me
3. 3. If I am in trouble no one will help
4. 4. The world is dangerous

These beliefs can manifest in patients through anger towards healthcare providers, non-adherence to medical guidelines, missing appointments, dishonesty about medical history, and helplessness (statements like "everyone has fibroids").  Combine the patient beliefs and behavior with possible healthcare provider responses, and you have a recipe for disaster.  

Let's keep in mind that hospitals and doctors in New York City are overworked and fatigued and it has been reported that in the healthcare industry, 40% of medical professionals have experienced trauma themselves.  You have patients triggering doctors, doctors triggering patients, and women dying in the midst of it. 

What does abuse look like in the hospital room?

• forced episiotomies
• not taking patients seriously, misdiagnosing, dismissing and minimizing pain. This can lead to missed symptoms and can be deadly  (Kira Johnson, Serena Williams) 
• restrictions during labor - ECBA vs. Montefiore Medical Center, Bronx, NY, 2018 
• healthcare providers questioning or making discouraging statements regarding personal autonomy (i.e. a 28-year-old wants a tubal ligation after birth, refused by a doctor who also said her body was great for more children)
• obstretic violence
• use of force
• disrespect and abuse
• forcing positions
• pushing legs back without permission
• premature forced pushing
• forced membrane rupture or membrane sweeping (breaking water bag)
• forced membrane stripping
• nonconsensual transvaginal ultrasounds 
• using sexualized language that mirrors sexual trauma in medical procedures and routines (often unintended but still rape culture)
• non consensual vacuum extraction
• non consensual forceps use
• persons in birthing room unapproved by birthing person (resident doctors, visitors, etc)
• presence of abuser in birthing room
• non-consensual insertions into laboring persons vagina

What does trauma show up like in birth?  

The neurophysiology and biology of trauma causes long term effects on the brain and body.  Four main hormones are released in our body which regulate trauma  - Catecholamines, Cortisol, Opiates, and Oxytocin. These hormones regulate the fight or flight response.  There is another, less known response that manifests during trauma — freezing, or trauma induced paralysis. This response can be experienced during labor and delivery.

The transition stage of labor — the final phase of the first part of labor in which the cervix dilates 7-10 cm — is sometimes described as feeling like an outer body experience, where unresolved and superimposed trauma can be re-triggering if not noticed or resolved.  It can feel like a separation of mind and body, but it can also manifest as crying, trembling, blacking out, feelings of loss of control, or loss of consciousness, and becoming disengaged from the birth, or wailing. 

A manifestation of trauma that occurs during the transition phase is spontaneous bearing down — a psychological trigger point in which the cervix responds and sends a signal to the brain, which for survivors of trauma may cause lack of oxygen, hyperventilation, and blood loss leading to fainting. Spontaneous bearing down may also be negatively impacted by past cervical scarring or injury. Spontaneous bearing down is felt right at the moment before crowning. The idea is that unconsciously, your body will not release the baby into an environment that you do not feel is safe. 

Improving maternal and child health outcomes requires tackling community and social and economic inequities.

Community doulas work to prevent victimization and re-traumatization in these healthcare settings and shift the culture inside the existing systems. 

Thoughts and comments are encouraged.  Please feel welcomed share any stories you may have.